Toddler Leroy Scott died because he wasn't given antibiotics soon enough

Julia Medew

A 15-month-old boy who lost his life to a bacterial infection three years ago would almost certainly be alive today if doctors at Geelong Hospital gave him antibiotics sooner than they did, a coroner has ruled.

The treatment delay was complicated by tardiness in carrying out various tests and miscommunication about those test results between doctors at the hospital and its pathology laboratory, which was operating on reduced hours over a public holiday weekend.

An inquest into Leroy William Scott's death heard the boy was a healthy, active toddler before he fell ill with an infection that eluded paediatricians for three days over the Anzac Day weekend of 2011.

Leroy had been taken to hospital on the night of Saturday, April 23, because he was vomiting and had a fever. Blood taken the following morning revealed bacteria resembling staphylococcus, a potentially fatal infection, and hospital staff were notified of the result about 10am on Monday April 25.

But two doctors caring for Leroy that day, including head of paediatrics David Fuller, decided to wait on further tests to confirm the result before antibiotics were prescribed because they suspected bacteria on his skin may have contaminated the result and that he had a viral infection instead.

However, by the time Dr Fuller and the other doctor, a registrar, went home on April 25, the results of the confirmatory tests had not been obtained. Despite an "on-call scientist" being available for pathology results, the registrar said she forgot to follow up on the test results because she was very busy and Dr Fuller said he believed the results were not available.

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By that evening, Leroy had a rash on his body and was wheezing. He continued to deteriorate overnight and by 6am on April 26 he was seriously ill with a heart rate of 200 beats per minute.

Despite being given antibiotics that morning, Leroy suffered a cardiac arrest about 10am.

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While staff were trying to resuscitate him, his test results arrived at 10:18am confirming he had Staphylococcus aureus in his blood, an infection that kills about one in 10 people. He died a short time later.

During the inquest, Dr Fuller conceded that when he saw Leroy about 8:20pm on April 25, he had failed to appreciate the extent of his deterioration as being due to a bacterial infection. He further conceded that in the context of unknown final blood test results, he should have commenced antibiotics at that time.

After investigating Leroy's death, Coroner Jacinta Heffey said it was both "unexpected and avoidable" and that Leroy would almost certainly have survived if antibiotics were given earlier. She also believed that the repetition of another test known as CRP should have been done on April 25 in the absence of the other test results to help doctors work out if Leroy had a bacterial infection, rather than a viral one.

"In most hospital deaths that become coronial investigations, the outcome of adopting a different clinical course is rarely so clear-cut," she wrote.

However, Ms Heffey said evidence from various doctors suggested the clinical decision-making in Leroy's case was not clear cut and that she therefore could not cast any doubt on Dr Fuller's competency.

"There is no evidence to suggest that he did not consider that he was acting in Leroy's best interests," she said.

Coroner Heffey called for better collaboration between Geelong Hospital and its laboratory, St John of God Pathology, and noted that Geelong Hospital had made several changes to its policies and procedures to try to prevent similar deaths from occurring in future.

On Thursday evening, Leroy's parents Kristine and Andre Scott said they were pleased the inquest had provided them with an apology from Dr Fuller and Barwon Health for the death of their beloved boy.

"The findings have highlighted a number of clinical and system failings, most significantly the failure to administer antibiotics when clearly indicated," they said in a written statement issued by their lawyer.